- Bites should be superficial, as thin as possible, not entering the atrium - Grasp tip of right atrial appendage with DeBakey forceps with slight cephalad/right tension - 2-0 ethibond suture - First bite, left face of caudal edge of appendage, forehand - Should not be so far down the appendage that atrioventricular groove and the RCA within it would be endangered in a repair stitch should this tissue rip - Even out suture tails - Pull appendage straight laterally - Second bite, left face thickened muscle bundle, forehand - Should not be so far down the appendage that atrioventricular groove and the RCA within it would be endangered in a repair stitch should this tissue rip - Pull appendage slight caudal/right tension - Third bite, left face of cephalad edge of appendage (or right through the edge itself), forehand - Pull appendage slight straight left tension - Fourth bite, right face, inverted forehand - Pull appendage slight cephalad/left - Fifth bite, right face of caudal edge of appendage, needle emerging fairly close to entry of first bite. - Use needle driver to clamp suture ends with needles - Snare suture ends with Rumel tourniquet - Cut needles off, hand back - Secure suture ends with Rumel, clamp Kelly over red rubber Robinson catheter, lay towards right side of bed. - Alterations in this cannulation stitch bite schedule depend on how "stubby" the right atrial appendage - Medium Stubbiness - Bites One, Two, and Three are necessarily closer to the tip - Bite Four is 'cheated' downwards - Bite Five can start deeper, but must end close to the entry of Bite one - Extreme Stubbiness - Here, the cannulation stitch resembles that of a redo right atrium[^a] - Start 2 cm or so below the tip of the atrial appendage - Take full thickness bites of right atrium, first with one arm of the suture, then with the other, describing what will be a circle that ends with both suture arms emerging at the most anterior edge of the right atrial appendage - Entry into this type of cannulation site is best accomplished with a Fifteen blade with a tonsil standing by to spread [^a]: Some people believe that this form of cannulation should be used in all valve cases that threaten the conduction system, as it preserves the atrial appendage tip for the "Pre-formed J" atrial pacing lead to be deployed.